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General NPI Number Information
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NPI Number | 1730264151
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Entity Type | Organization
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Legal Business Name | MORRISANIA DIAGNOSTIC AND TREATMENT CENTER
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Dates
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Enumeration Date | 10/25/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 158 E 115TH ST
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City | NEW YORK
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State | NY
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Zip | 10029-2031
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Country | US
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Telephone | 212-360-5919
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Fax | 212-828-0858
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Provider Business Mailing Address
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Address Line | 158 E 115TH ST
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City | NEW YORK
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State | NY
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Zip | 10029-2031
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Country | US
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Telephone | 212-360-5919
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Fax | 212-828-0858
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | NELLIE BOMA
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Credential | M.D.
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Telephone | 718-960-2793
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 144173
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License Number State | NY
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